Outlook for total joint replacements in the ASC: Key concepts from Dr. Thomas K. Miller

Thomas K. Miller, MD, is the section chief of sports medicine at Carilion Clinic in Roanoke, Va. He has long championed orthopedic procedures in the outpatient ASC and has a deep understanding of the roadblocks to, as well as opportunities for, total joint replacement in the ASC.

Dr. Miller will be speaking at the Becker's 16th Annual Future of Spine + The Orthopedic, Spine and Pain Management-Driven ASC Conference. To learn more and register, click here. Contact Maura Jodoin at mjodoin@beckershealthcare.com or Kristelle Khazzaka at Kkhazzaka@beckershealthcare.com for further information about sponsorship and exhibitor opportunities.

Question: What is the biggest roadblock you see to a nationwide trend of total joints being performed in the ASC? How can the industry jump-start more total joint centers?

Dr. T.K. Miller: From a fiscal perspective, centers are still limited by CMS constraints, although that seems to be changing with the expected permission to perform total knees in ASCs. With the realization that for select patients, nonhospital-based care represents fiscal responsibility and optimized use of resources, it is reasonable to expect other arthroplasty procedures will receive CMS approval to be performed in the ASC environment. Until that time, successful centers will need to continue to validate the net value (not just upfront cost, but also quality meeting or exceeding hospital-based services) as they develop viable contractual relationships with commercial carriers and large self-insured entities.

With strict perioperative protocols and realistic patient selection, from a global cost perspective, freestanding ASCs can be expected to be seen as the more fiscally appropriate sites of care, rather than hospital-associated ambulatory sites for a large number of patients. Industry support in the form of cost-competitive implants, DME supplies and other procedure and perioperative-based expenses (perhaps as a total joint "package") will allow centers "on the fence" to perform fiscal reviews and may engage sites not currently willing to assume the financial risk of developing and advancing a program.

Q: Where do you see the biggest opportunity for growth among total joint programs at ASCs? Where can orthopedic ASCs grow the most over the next 5 years?

TM: Expansion of operative services to include anterior-approach total hips seems to be the procedure that best fits patient profiles, pain management requirements, immediate perioperative needs and ambulatory ability post-procedure, and should be a prime opportunity for growth.

Shoulder arthroplasty is also an underconsidered procedure at this time. The other site of growth continues with spine. Not just limited exposure and single-level intervention, but extended level fusion, especially if extended stay or 23-hour capability is included.

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